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A benign cystic teratoma of the ovary with chronic thyroiditis
1142 Communications in brief
lated to the 25-0HD concentration. The urinary excretion of cAMP tended to be lower in the heparintreated women, but was not significantly different from that in the control group. The excretion of this nucleotide closely reflects the circulating level of parathyroid hormone. The results of the study confirm that heparin treatment reduces the serum concentration of 1 ,2 5-(0H )2 D. The mechanism for this action remains unclear. A possible direct action of heparin includes impairment of I a-hydroxylase, which converts 25-0HD to 1,25(0HhD in the renal tubuli. Recently, it was shown that heparin inhibits the production of 1 ,25-(0HhD in kidney homogenates of Japanese quail, thereby suggesting that heparin may impair the conversion of 25-0HD to 1 ,25-(0HhD by a direct effect on the la-hydroxylase. 2 The effect of heparin on vitamin D metabolism is probably only of clinical significance in patients on long-term treatment with high doses of heparin, whereas the lower doses used in prophylaxis do not seem to impair the production of 1,25-(0HhD to such an extent as to make preventive measures necessary. REFERENCES 1. Aarskog, D., Aksnes, L., and Lehmann, V.: Low 1,25-
dihydroxyvitamin D in heparin-induced osteopenia, Lancet 2:650, 1980. 2. Vander Vijgh, W. J. F., Kruik, A. J. B., Jongen, M. J. M., Lips, P., and Netelenbos, J. C.: Inhibition of 25(0H)D !a-hydroxylase in kidney homogenates of Japanese quails by heparin, Calcif. Tissue Int. (Suppl.) 35:50, 1983.
A benign cystic teratoma of the ovary with chronic thyroiditis Vibeke T. Nielsen, M.D. Institute of Pathology, Holstebro, DenrrULrk
Despite many case reports and review articles concerning mature cystic teratomas (dermoid cysts) of the ovary, Hashimoto's thyroiditis in a cystic teratoma seems to have been described only once. 1 Therefore, a second case with a somewhat different clinical picture is reported here. In 1975, a 29-year-old woman (gravida 3, para 2) was admitted to a medical department because of oligomenorrhea of 2 years' duration. Her last delivery had been in 1971, and she had taken no oral contraceptives since then. Gynecologic examination was unremarkable. The urinary 17-ketosteroid excretion was 14.1 mg/24 hr (normal range, 3 to 15 mg/24 hr), with increased androsterone, etiocholanolone, and dehydroepiandrosterone fractions. Plasma follicle-stimulating hormone and luteinizing hormone were within normal limits. The patient exhibited normal adrenocortical suppression during the administration of dexamethaReprint requests: Vibeke T. Nielsen, M.D., Institute of Pathology, Skive sygehus, DK-7800 Skive, Denmark.
April 15, 1984 Am. J. Obstet. Gynecol.
sone. The right lobe of the thyroid gland was questionably enlarged, and the thyroid function tests were normal. She had no hirsutism. In 1977, the patient was rehospitalized with persisting oligomenorrhea. Both ovaries were now enlarged. At laparotomy, a left salpingo-oophorectomy and a wedge resection of the right ovary were performed. Since the operative treatment, the patient has menstruated regularly and has been healthy, without signs of thyroid disease. Three weeks after the operation, the patient's serum was tested for antibodies to thyroglobulin, the second component of colloid, and microsomal antigen, with negative results. Gross pathologic examination showed that the left ovary was transformed into a single and thin-walled cyst that measured 6 by 5 by 4 em. The polycystic right ovary was 7 by 5 by 5 em in size, and the wedge resection measured 5 by 3 by 2 em. Sectioning of the latter tissue revealed a multilocular cyst with a few hairs and a tooth. Histologically, the wedge resection from the right ovary showed, in an otherwise typical benign cystic teratoma, an area that contained thyroid tissue with changes like that in Hashimoto's thyroiditis. The follicular architecture was somewhat disturbed by fibrosis, and the tissue was heavily infiltrated with lymphocytes and plasma cells (Fig. I). The follicular epithelium showed a pronounced degree of socalled benign degenerative nuclear pleomorphism, and the cytoplasm was abundant and oxyphilic (Fig. 2). No mitoses were found. In the case reported by Erez and associates,! the patient had chronic thyroiditis, demonstrated by removal of the isthmus and the anterior portion of the right lower lobe of the thyroid gland. Whether the remainder of the thyroid gland was normal was not stated. Seven years later, the patient's ovarian cystic teratoma was detected and showed an area with changes similar to Hashimoto's thyroiditis. The serum was tested for antibody to thyroglobulin 8 months after the operation, with negative results. In our patient, no signs of thyroid disease were found, neither before nor after the removal of the ovarian cystic teratoma, except for a dubiously enlarged right lobe of the thyroid gland. For ethical reasons, we did not perform a thyroid biopsy. The patient's cystic teratoma contained a small area of thyroid tissue with an appearance like that in Hashimoto's thyroiditis. Erez and associates speculated that, if their patient had had the cystic teratoma removed in time, thyroiditis might not have developed. However, the question is whether the histologic changes in the two cases are really expressions of Hashimoto's thyroiditis. The overlapping of the histologic features of Hashimoto's thyroiditis and those of focal chronic thyroiditis is remarkable, and immunohistologic findings 2 show many cases with features of both. Intermediate forms do presumably exist. Generally, the concentrations of thyroid antibodies in the serum correlate only roughly with the extent of thyroid lymphocytic infiltrates and can be low in both Hashimoto's thyroiditis and in focal chronic thyroiditis. Still, in the classic form of Hashimoto's thyroiditis, the glandular involvement is nearly always diffuse and symmetrical, and the titer of thyroid autoantibody is usually high. Thus, it seems questionable that
Volume 148 Number 8
Communications in brief
Fig. l. Wall of the cystic teratoma with mature bone and focal chronic thyroiditis.
Fig. 2. Remarkable benign nuclear pleomorphism of the follicular epithelium and numerous lymphocytes and plasma cells in the stroma.
1143
1144 Communications in brief
April 15, 1984 Am. J. Obstet. Gynecol.
both patients with negative titers should suffer from a "real" Hashimoto's thyroiditis. Unfortunately, the titers in the two patients were not measured before the operations. Presumably, the changes in the cystic teratomas of both patients may be regarded as focal chronic thyroiditis or as an "intermediate" form of thyroiditis. Polycystic ovarian syndrome with increased urinary 17-ketosteroid levels and unilateral or bilateral cystic teratomas has been described, and our patient probably falls into this category, although she had no hirsutism.
REFERENCES l. Erez, S. E., Richart, R. M., and Shettles, L. B.: Hashimoto's disease in a benign cystic teratoma of the ovary, AM. J. 0BSTET. G YNECOL. 92:2 73, I 963. 2. Knecht, H., Saremaslani, P., and Hedinger, C.: Immunohistological findings in Hashimoto's thyroiditis, focal lymphocytic thyroiditis and thyroiditis de Quervain, Virchows Arch. (Pathol. Anat.) 393:215, I98l.
Abruptio placentae: An unusual ultrasonic presentation L. M. Hill, M.D., R. Breckle, R.T., R.D.M.S., and
W. Gehrking, R.D.M.S. Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota
The incidence of abruptio placenta approaches l %. 1 Clinical findings associated with an abruptio placentae might include vaginal bleeding, uterine tenderness, a hypertonic uterus, fetal distress, and disseminated intravascular coagulopathy. The usefulness of sonography in evaluating the third-trimester patient with vaginal bleeding lies in its ability to rule in or out the diagnosis of placenta previa. There is a recognized lack of sensitivity in the ability of ultrasound to diagnose retroplacental hemorrhage. The purpose of this report is to make the obstetrician aware of an unusual ultrasonic presentation of abruptio placentae-the presence of intra-amniotic blood clot. C. W., a 24-year-old woman, gravida 2, para I, had a regular menstrual cycle. A pregnancy test was positive 6 weeks after her last menstrual period. Findings at examination at I 0 weeks, 5 days were consistent with the patient's dates. Blood type was A, Rh positive, and the hemoglobin was I3.l gm/dl. The blood pressure was I20/60 torr. She did not smoke. The patient was admitted to the hospital at 32 Y2 weeks' gestation complaining of lower abdominal and back pain that had been persistent for approximately 36 hours. Examination disclosed that the uterus was nontender. Fetal heart tones were auscultated in the left lower quadrant and were within
Reprint requests: Dr. L. M. Hill, Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN 55905.
Fig. I. Transverse scan in which the relationship between the fetal abdomen (a) and intra-amniotic blood clot (b) is illustrated (e = extremity). normal limits. The cervix was 2 5% effaced and dilated I em. The patient's initial laboratory data included a hemoglobin of II.3 gm/dl; a platelet count of I99,000/mm3 ; fibrin split products of IO to 40 J,Lg/ml; and a fibrinogen of I43 mg/dl (normal nonpregnant range, I90 to 265 mg/dl). Prothrombin time and partial thromboplastin time were normal. On ultrasound examination, a single fetus was noted in vertex presentation. The biparietal diameter was consistent with the patient's stated gestational age. The placenta was left posterior corpus-fundus in location. An adequate amount of amniotic fluid was present. Fetal cardiac activity and breathing movements were noted on real time. The ultrasonic estimation of fetal weight was 2,000 gm. Within the right lower quadrant of the amniotic cavity was an irregular echogenic mass that appeared to be free-floating; separation from the fetus and differentiation from the placenta were possible ultrasonically. The mass measured 5 by 6 by 7 em (Figs. I and 2). Three hours after the ultrasound examination, spontaneous rupture of the membranes occurred. One hundred fifty milliliters of dark blood was lost via the vagina. The cervix was dilated 3 em. A fetal tachycardia of I 70 bpm was present in association with persistent moderate variable decelerations. With a presumptive diagnosis of abruptio placentae and fetal distress, a primary low transverse cesarean section was performed. At the time of the uterine incision, a 200 ml blood clot was delivered prior to the infant. This had been the mass that was detected previously on ultrasound. An 1 ,890 gm male infant was delivered, with Apgar scores of 5 and 8 at I and 5 minutes, respectively. Frank blood was obtained upon tracheobronchial and stomach aspiration. The neonate was also passing blood via the rectum, but there was no blood within the neonate's stool after 36 hours, thus indicating that the source of the blood had been the in utero swallowing of
lated to the 25-0HD concentration. The urinary excretion of cAMP tended to be lower in the heparintreated women, but was not significantly different from that in the control group. The excretion of this nucleotide closely reflects the circulating level of parathyroid hormone. The results of the study confirm that heparin treatment reduces the serum concentration of 1 ,2 5-(0H )2 D. The mechanism for this action remains unclear. A possible direct action of heparin includes impairment of I a-hydroxylase, which converts 25-0HD to 1,25(0HhD in the renal tubuli. Recently, it was shown that heparin inhibits the production of 1 ,25-(0HhD in kidney homogenates of Japanese quail, thereby suggesting that heparin may impair the conversion of 25-0HD to 1 ,25-(0HhD by a direct effect on the la-hydroxylase. 2 The effect of heparin on vitamin D metabolism is probably only of clinical significance in patients on long-term treatment with high doses of heparin, whereas the lower doses used in prophylaxis do not seem to impair the production of 1,25-(0HhD to such an extent as to make preventive measures necessary. REFERENCES 1. Aarskog, D., Aksnes, L., and Lehmann, V.: Low 1,25-
dihydroxyvitamin D in heparin-induced osteopenia, Lancet 2:650, 1980. 2. Vander Vijgh, W. J. F., Kruik, A. J. B., Jongen, M. J. M., Lips, P., and Netelenbos, J. C.: Inhibition of 25(0H)D !a-hydroxylase in kidney homogenates of Japanese quails by heparin, Calcif. Tissue Int. (Suppl.) 35:50, 1983.
A benign cystic teratoma of the ovary with chronic thyroiditis Vibeke T. Nielsen, M.D. Institute of Pathology, Holstebro, DenrrULrk
Despite many case reports and review articles concerning mature cystic teratomas (dermoid cysts) of the ovary, Hashimoto's thyroiditis in a cystic teratoma seems to have been described only once. 1 Therefore, a second case with a somewhat different clinical picture is reported here. In 1975, a 29-year-old woman (gravida 3, para 2) was admitted to a medical department because of oligomenorrhea of 2 years' duration. Her last delivery had been in 1971, and she had taken no oral contraceptives since then. Gynecologic examination was unremarkable. The urinary 17-ketosteroid excretion was 14.1 mg/24 hr (normal range, 3 to 15 mg/24 hr), with increased androsterone, etiocholanolone, and dehydroepiandrosterone fractions. Plasma follicle-stimulating hormone and luteinizing hormone were within normal limits. The patient exhibited normal adrenocortical suppression during the administration of dexamethaReprint requests: Vibeke T. Nielsen, M.D., Institute of Pathology, Skive sygehus, DK-7800 Skive, Denmark.
April 15, 1984 Am. J. Obstet. Gynecol.
sone. The right lobe of the thyroid gland was questionably enlarged, and the thyroid function tests were normal. She had no hirsutism. In 1977, the patient was rehospitalized with persisting oligomenorrhea. Both ovaries were now enlarged. At laparotomy, a left salpingo-oophorectomy and a wedge resection of the right ovary were performed. Since the operative treatment, the patient has menstruated regularly and has been healthy, without signs of thyroid disease. Three weeks after the operation, the patient's serum was tested for antibodies to thyroglobulin, the second component of colloid, and microsomal antigen, with negative results. Gross pathologic examination showed that the left ovary was transformed into a single and thin-walled cyst that measured 6 by 5 by 4 em. The polycystic right ovary was 7 by 5 by 5 em in size, and the wedge resection measured 5 by 3 by 2 em. Sectioning of the latter tissue revealed a multilocular cyst with a few hairs and a tooth. Histologically, the wedge resection from the right ovary showed, in an otherwise typical benign cystic teratoma, an area that contained thyroid tissue with changes like that in Hashimoto's thyroiditis. The follicular architecture was somewhat disturbed by fibrosis, and the tissue was heavily infiltrated with lymphocytes and plasma cells (Fig. I). The follicular epithelium showed a pronounced degree of socalled benign degenerative nuclear pleomorphism, and the cytoplasm was abundant and oxyphilic (Fig. 2). No mitoses were found. In the case reported by Erez and associates,! the patient had chronic thyroiditis, demonstrated by removal of the isthmus and the anterior portion of the right lower lobe of the thyroid gland. Whether the remainder of the thyroid gland was normal was not stated. Seven years later, the patient's ovarian cystic teratoma was detected and showed an area with changes similar to Hashimoto's thyroiditis. The serum was tested for antibody to thyroglobulin 8 months after the operation, with negative results. In our patient, no signs of thyroid disease were found, neither before nor after the removal of the ovarian cystic teratoma, except for a dubiously enlarged right lobe of the thyroid gland. For ethical reasons, we did not perform a thyroid biopsy. The patient's cystic teratoma contained a small area of thyroid tissue with an appearance like that in Hashimoto's thyroiditis. Erez and associates speculated that, if their patient had had the cystic teratoma removed in time, thyroiditis might not have developed. However, the question is whether the histologic changes in the two cases are really expressions of Hashimoto's thyroiditis. The overlapping of the histologic features of Hashimoto's thyroiditis and those of focal chronic thyroiditis is remarkable, and immunohistologic findings 2 show many cases with features of both. Intermediate forms do presumably exist. Generally, the concentrations of thyroid antibodies in the serum correlate only roughly with the extent of thyroid lymphocytic infiltrates and can be low in both Hashimoto's thyroiditis and in focal chronic thyroiditis. Still, in the classic form of Hashimoto's thyroiditis, the glandular involvement is nearly always diffuse and symmetrical, and the titer of thyroid autoantibody is usually high. Thus, it seems questionable that
Volume 148 Number 8
Communications in brief
Fig. l. Wall of the cystic teratoma with mature bone and focal chronic thyroiditis.
Fig. 2. Remarkable benign nuclear pleomorphism of the follicular epithelium and numerous lymphocytes and plasma cells in the stroma.
1143
1144 Communications in brief
April 15, 1984 Am. J. Obstet. Gynecol.
both patients with negative titers should suffer from a "real" Hashimoto's thyroiditis. Unfortunately, the titers in the two patients were not measured before the operations. Presumably, the changes in the cystic teratomas of both patients may be regarded as focal chronic thyroiditis or as an "intermediate" form of thyroiditis. Polycystic ovarian syndrome with increased urinary 17-ketosteroid levels and unilateral or bilateral cystic teratomas has been described, and our patient probably falls into this category, although she had no hirsutism.
REFERENCES l. Erez, S. E., Richart, R. M., and Shettles, L. B.: Hashimoto's disease in a benign cystic teratoma of the ovary, AM. J. 0BSTET. G YNECOL. 92:2 73, I 963. 2. Knecht, H., Saremaslani, P., and Hedinger, C.: Immunohistological findings in Hashimoto's thyroiditis, focal lymphocytic thyroiditis and thyroiditis de Quervain, Virchows Arch. (Pathol. Anat.) 393:215, I98l.
Abruptio placentae: An unusual ultrasonic presentation L. M. Hill, M.D., R. Breckle, R.T., R.D.M.S., and
W. Gehrking, R.D.M.S. Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota
The incidence of abruptio placenta approaches l %. 1 Clinical findings associated with an abruptio placentae might include vaginal bleeding, uterine tenderness, a hypertonic uterus, fetal distress, and disseminated intravascular coagulopathy. The usefulness of sonography in evaluating the third-trimester patient with vaginal bleeding lies in its ability to rule in or out the diagnosis of placenta previa. There is a recognized lack of sensitivity in the ability of ultrasound to diagnose retroplacental hemorrhage. The purpose of this report is to make the obstetrician aware of an unusual ultrasonic presentation of abruptio placentae-the presence of intra-amniotic blood clot. C. W., a 24-year-old woman, gravida 2, para I, had a regular menstrual cycle. A pregnancy test was positive 6 weeks after her last menstrual period. Findings at examination at I 0 weeks, 5 days were consistent with the patient's dates. Blood type was A, Rh positive, and the hemoglobin was I3.l gm/dl. The blood pressure was I20/60 torr. She did not smoke. The patient was admitted to the hospital at 32 Y2 weeks' gestation complaining of lower abdominal and back pain that had been persistent for approximately 36 hours. Examination disclosed that the uterus was nontender. Fetal heart tones were auscultated in the left lower quadrant and were within
Reprint requests: Dr. L. M. Hill, Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN 55905.
Fig. I. Transverse scan in which the relationship between the fetal abdomen (a) and intra-amniotic blood clot (b) is illustrated (e = extremity). normal limits. The cervix was 2 5% effaced and dilated I em. The patient's initial laboratory data included a hemoglobin of II.3 gm/dl; a platelet count of I99,000/mm3 ; fibrin split products of IO to 40 J,Lg/ml; and a fibrinogen of I43 mg/dl (normal nonpregnant range, I90 to 265 mg/dl). Prothrombin time and partial thromboplastin time were normal. On ultrasound examination, a single fetus was noted in vertex presentation. The biparietal diameter was consistent with the patient's stated gestational age. The placenta was left posterior corpus-fundus in location. An adequate amount of amniotic fluid was present. Fetal cardiac activity and breathing movements were noted on real time. The ultrasonic estimation of fetal weight was 2,000 gm. Within the right lower quadrant of the amniotic cavity was an irregular echogenic mass that appeared to be free-floating; separation from the fetus and differentiation from the placenta were possible ultrasonically. The mass measured 5 by 6 by 7 em (Figs. I and 2). Three hours after the ultrasound examination, spontaneous rupture of the membranes occurred. One hundred fifty milliliters of dark blood was lost via the vagina. The cervix was dilated 3 em. A fetal tachycardia of I 70 bpm was present in association with persistent moderate variable decelerations. With a presumptive diagnosis of abruptio placentae and fetal distress, a primary low transverse cesarean section was performed. At the time of the uterine incision, a 200 ml blood clot was delivered prior to the infant. This had been the mass that was detected previously on ultrasound. An 1 ,890 gm male infant was delivered, with Apgar scores of 5 and 8 at I and 5 minutes, respectively. Frank blood was obtained upon tracheobronchial and stomach aspiration. The neonate was also passing blood via the rectum, but there was no blood within the neonate's stool after 36 hours, thus indicating that the source of the blood had been the in utero swallowing of